Form WC-367 "Respondent's Answer to Claim Petition" - New Jersey

What Is Form WC-367?

This is a legal form that was released by the New Jersey Department of Labor & Workforce Development - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 4, 2015;
  • The latest edition provided by the New Jersey Department of Labor & Workforce Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WC-367 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Labor & Workforce Development.

ADVERTISEMENT
ADVERTISEMENT

Download Form WC-367 "Respondent's Answer to Claim Petition" - New Jersey

1246 times
Rate (4.6 / 5) 62 votes
State of New Jersey
RESPONDENT’S ANSWER TO
Department of Labor and Workforce Development
Case No.: _____________________________
CLAIM PETITION
Division of Workers’ Compensation
PO Box 381
Vicinage:
_____________________________
Trenton, New Jersey 08625-0381
WC-367 r. 5/4/2015
ORIGINAL ANSWER
AMENDED ANSWER
SOCIAL SECURITY OR IDENTIFICATION NUMBER:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER:
VS
NAME:
NAME:
ADDRESS:
ADDRESS:
CORRECT NAME OF RESPONDENT IF INCORRECT ON CLAIM PETITION:
CARRIER CLAIM NUMBER:
IN ANSWER TO CLAIM PETITION IN THIS CAUSE
NAME:
RESPONDENT STATES:
ADDRESS:
Petitioner was in employment on date
Correct date of accident or exposure if
alleged in petition:
incorrect on Claim Petition:
YES
NO
Arose out of and in the course of
Coverage was provided on date of
TPA CLAIM NUMBER:
employment:
accident or exposure:
YES
NO
YES
NO
How and where injury or disease occurred:
Nature of injury or disease:
Petitioner’s occupation:
Date respondent had knowledge or notice of injury or
Date petitioner stopped work:
Date returned to work:
disease:
Wage Period:
Gross Wages:
Rate of compensation:
Weeks Temporary Paid:
Temporary Payments continuing:
Temporary disability paid:
$
$
$
YES
NO
Permanent Disability:
Paid
or being paid
_________ % disability of _______________________ (# ___________weeks @ $___________________totaling $___________________)
Respondent rendered aid to the petitioner:
If YES, please list the individuals and/or institutions providing aid or treatment:
YES
NO
The Respondent reserves the right to cross examine all physicians upon whom the petitioner will rely in proof of the claim
Other pertinent information:
See page 2
Demand is hereby made for answers to standard occupational disease interrogatories [N.J.A.C. 12:235-3.8(f)]
Demand is hereby made for all records of medical treatment, examinations and diagnostic studies [N.J.A.C. 12:235-3.8 (c)]
I certify that the foregoing statements made by me are true to the best of my knowledge, information and belief.
_________________________________________________________
___________________________
Attorney for the Respondent
Date
State of New Jersey
RESPONDENT’S ANSWER TO
Department of Labor and Workforce Development
Case No.: _____________________________
CLAIM PETITION
Division of Workers’ Compensation
PO Box 381
Vicinage:
_____________________________
Trenton, New Jersey 08625-0381
WC-367 r. 5/4/2015
ORIGINAL ANSWER
AMENDED ANSWER
SOCIAL SECURITY OR IDENTIFICATION NUMBER:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER:
VS
NAME:
NAME:
ADDRESS:
ADDRESS:
CORRECT NAME OF RESPONDENT IF INCORRECT ON CLAIM PETITION:
CARRIER CLAIM NUMBER:
IN ANSWER TO CLAIM PETITION IN THIS CAUSE
NAME:
RESPONDENT STATES:
ADDRESS:
Petitioner was in employment on date
Correct date of accident or exposure if
alleged in petition:
incorrect on Claim Petition:
YES
NO
Arose out of and in the course of
Coverage was provided on date of
TPA CLAIM NUMBER:
employment:
accident or exposure:
YES
NO
YES
NO
How and where injury or disease occurred:
Nature of injury or disease:
Petitioner’s occupation:
Date respondent had knowledge or notice of injury or
Date petitioner stopped work:
Date returned to work:
disease:
Wage Period:
Gross Wages:
Rate of compensation:
Weeks Temporary Paid:
Temporary Payments continuing:
Temporary disability paid:
$
$
$
YES
NO
Permanent Disability:
Paid
or being paid
_________ % disability of _______________________ (# ___________weeks @ $___________________totaling $___________________)
Respondent rendered aid to the petitioner:
If YES, please list the individuals and/or institutions providing aid or treatment:
YES
NO
The Respondent reserves the right to cross examine all physicians upon whom the petitioner will rely in proof of the claim
Other pertinent information:
See page 2
Demand is hereby made for answers to standard occupational disease interrogatories [N.J.A.C. 12:235-3.8(f)]
Demand is hereby made for all records of medical treatment, examinations and diagnostic studies [N.J.A.C. 12:235-3.8 (c)]
I certify that the foregoing statements made by me are true to the best of my knowledge, information and belief.
_________________________________________________________
___________________________
Attorney for the Respondent
Date